Mindfulness-based pain management

1. Introduction

Version followed: Breathworks Mindfulness for Health 8-week course (the main way MBPM is delivered), as set out in Burch & Penman 2013, Mindfulness for Health (US title You Are Not Your Pain), and on the current Breathworks course pages. The stage model follows Burch 2016 as reported in secondary sources. The older five-step model in Burch 2008/2010, Living Well with Pain and Illness, is noted where it differs. The books themselves are not drawn on, so any step-level detail taken from them is tagged [uncertain].

Mindfulness-based pain management (MBPM) is a mindfulness and compassion programme for people with chronic pain, illness or fatigue. Vidyamala Burch developed it from her own experience of spinal injury and pain. It began as a 2001 pilot and has been run by Breathworks (Manchester, UK) since 2004. It adapts MBSR and MBCT: meditations are shorter, movement is gentle and adaptable, and it adds a pacing programme taken from pain management, plus a strong emphasis on kindness and compassion [source: Wikipedia MBPM; Wikipedia Breathworks; Breathworks course overview].

How change happens. Pain is split into two parts:

Primary suffering is the unpleasant sensation itself, which cannot be avoided.
Secondary suffering is the resistance, fear, low mood, catastrophising and extra tension added on top.

Turning towards primary sensations with kindly, present-moment awareness reduces secondary suffering. Burch describes this as learning to "turn towards your experience, even if it's painful" [source: Garrison Institute interview]. Clients learn to breathe into experience instead of tensing against it, to respond instead of react, and to manage activity in a balanced way rather than swinging between overdoing and collapse [source: Breathworks course overview]. The aim is a changed relationship to the condition, not removal of the condition [source: Breathworks MBHI page].

2. Framework

Format [source: Breathworks course overview; Breathworks MBHI page; Wikipedia MBPM; franticworld extra materials]

Course: 8 weekly group sessions, run by an accredited Breathworks teacher. Clients self-refer. Typical conditions include back pain, arthritis, fibromyalgia, chronic fatigue, post-operative pain, cancer, MS and Parkinson's.
Session length: sessions were 2.5–3 hours in the original in-person format. Current online listings show about 90–120 minutes. Since 2020 most courses run live online.
Other formats: a self-paced online course (alone or with a web group led by an accredited teacher), suited to housebound clients. The book can also be used for self-guided practice.
Pre-course reading: clients read chapter 4 of the book before week 1. Chapters 1–3 are recommended.
Home practice: about 20 minutes a day, as two roughly 10-minute guided meditations, plus short daily-life practices and diaries. The 2 × 10 minute split is [uncertain]; it is inferred from the 10-minute meditation length and the 20-minute total.
Meditations: seven guided meditations of about 10 minutes each, building on one another, plus the Three-Minute Breathing Space. Teacher-led sessions use longer versions.

Stages (six-stage process, Burch 2016 via secondary sources) [source: Wikipedia MBPM; Wikipedia Breathworks]

Stage	Goal	Main practice	Week
1. Awareness	Build steady, basic awareness of body and breath; stabilise attention (samatha)	Body Scan; Breathing Anchor; Mindful Movement	1–3
2. Acceptance	Turn towards the unpleasant with kindness; reduce blocking and drowning	Compassionate Acceptance	4
3. Wonder (seeking the pleasant)	Notice and savour pleasant experience that sits alongside pain	Treasure of Pleasure	5
4. Equanimity	Hold pleasant and unpleasant within a broader, steadier awareness	Open Heart	6
5. Connection	Widen from personal suffering to shared humanity; kindness to others	Connection	7
6. Choice	Respond rather than react, in daily life and in activity	Mindfulness in daily life; pacing; planning ongoing practice	Throughout; consolidated in week 8

Weekly content as indexed by the book's resource pages [source: Breathworks and franticworld extra-materials pages]

Ch. 3 (before starting): posture. Sitting, lying, and getting down to and up from the floor.
Week 1 (Ch. 4): Body Scan; breathing and the "three diaphragms".
Week 2 (Ch. 5): Breathing Anchor; "doing" and "being" modes; the "Coming to Your Senses" chart, adapted from Mark Williams.
Week 3 (Ch. 6): Mindful Movement; introduction to pacing; Mindfulness in Daily Life diary.
Week 4 (Ch. 7): Compassionate Acceptance; Blocking and Drowning handout; diary analysis, rest-period analysis and baseline record sheets.
Weeks 5–8 (Ch. 8–11): the resource pages list a practice PDF for each week but give no further detail. The weekly themes come from the table above.

The Breathworks site uses a different grouping of meditations, adding the stress course and a Kindness to Self meditation [source: Breathworks compassion blog].

Older five-step version [uncertain; Burch 2008/2010]: awareness; moving towards the unpleasant; seeking the pleasant; broadening awareness; choosing to respond. This covers the same ground without the separate connection stage.

Moving between stages. The sources give no formal criteria for moving on. The course moves forward weekly and each practice builds on the last. The sequence goes from focused attention, to open, non-reactive awareness, to kindness and compassion, and from the individual to the interpersonal [source: Wikipedia MBPM]. If you are adapting the course for individual therapy, practical readiness markers are [synthesis]:

the client can rest attention on the breath and body for about 10 minutes and come back after drifting, before you start acceptance work
the client can name blocking or drowning when it happens, before you go deep into the pleasant
the client has kept a diary for at least a week before you set baselines

Training and accreditation [source: Breathworks course overview; Breathworks MBHI page; Wikipedia Breathworks]

Breathworks teacher training has Stage One and Stage Two, plus an MBSR conversion route for qualified MBSR teachers.
Training follows the BAMBA Good Practice Guidelines.
Only accredited teachers may deliver the branded course. A therapist using these methods without accreditation should present them as "informed by" MBPM [synthesis].

3. Guiding principles

Tagged [source: …] where documented; the one-line practical meanings are [synthesis].

Two arrows: primary vs secondary suffering [source: Wikipedia MBPM; Garrison interview]. Work on the layer the client can change, which is resistance, not the sensation itself. Do not promise less pain.
Turn towards, don't escape [source: Garrison interview]. Practices are not for dissociating from pain. Invite gentle curiosity about where it is and what it feels like.
Breathe into experience rather than tensing against it [source: Breathworks course overview]. The breath is both the anchor and a way to soften around sensation. Keep coming back to the felt breath in the body.
Respond rather than react [source: Breathworks course overview]. Every exercise ends in a choice point: what is the kind, wise next move?
Kindness and compassion throughout [source: Wikipedia MBPM; Breathworks compassion blog]. Self-kindness is taught as a skill, being "on your side". The emotional tone of attention matters as much as the attention itself.
Wellness within illness [source: Doran 2014 via polio poster]. Help the client find what is still well and pleasant without denying the pain.
Balanced activity: neither boom nor bust [source: Breathworks course overview]. Avoid overdoing it on good days and collapsing on bad ones. Pacing is mindfulness applied to activity.
Short and adaptable [source: Wikipedia MBPM; Breathworks course overview]. Ten-minute practices, any comfortable posture, movement adapted to the body. Never ask a client to hold a painful posture to "sit through" it.
Secular, with contemplative roots [source: Wikipedia Breathworks]. The course draws on Buddhist training, offered without religious content. Use plain language and make no faith demands.
Teach from your own practice [source: Breathworks compassion blog]. Teachers have long personal practice. Do not teach a practice you have not done yourself repeatedly.
Changed relationship, not cure [source: Breathworks MBHI page]. Set goals around living well, function and distress, not pain scores alone.

4. Intervention inventory

Scope and sourcing [source: Breathworks course overview; Breathworks and franticworld extra-materials pages; Breathworks compassion blog; franticworld free meditations].

What the sources confirm: the name of each intervention, its purpose and which week it belongs to.
What they do not give: the step-by-step scripts. These are in the copyrighted book and audio, which are not drawn on. The steps below are therefore in my own words, built from the documented purpose of each practice and standard practice in mindfulness-based programmes [synthesis].
Where detail is tagged [uncertain]: detail recalled from Burch's books that is not checked.
Breathworks audio: for the actual guided audio, use Breathworks' licensed recordings. The Breathing Anchor and the Three-Minute Breathing Space are available free from the book's site.

Posture set-up (before week 1)

Purpose: find a supported, sustainable position so the practice does not itself become a source of pain. The book's ch. 3 covers sitting, lying, and getting down to and up from the floor [source: extra-materials pages].
Steps [synthesis]:
1. Ask which positions the client can hold comfortably for 10 minutes: lying, reclined, chair, or floor with cushions.
2. Add support under knees, lower back, neck and arms until no muscle has to work to hold the position.
3. Agree that the client may move at any time, slowly and with awareness.
4. If getting down to the floor or up from it is painful, practise that transition mindfully as an exercise in its own right.
Example language (illustrative): "Let's set you up so your body is held by the chair and cushions, not by your muscles. Moving during practice is fine. Just move slowly and notice it."
Watch for: bracing; holding still out of a belief that moving is "failing"; flare-ups after floor work. It is working when the client can settle within a minute or two and changes position without self-criticism.

Breath awareness and whole-body breathing ("three diaphragms")

Purpose: explore breathing habits and use the natural breath to ease pain and stress. Clients notice where breathing is held or shallow and let the breath move more fully through the body [source: Breathworks course overview].
Background: Burch wrote a handout and a guided meditation on breathing physiology and the "three diaphragms". Donna Farhi's The Breathing Book is recommended alongside [source: extra-materials pages]. Which three diaphragms are meant is [uncertain].
Steps [synthesis]:
1. Settle into a supported posture.
2. Notice where the breath moves (belly, sides, back, chest) without changing it.
3. Notice any holding: a tight belly, clenched jaw, braced pelvis.
4. Let the breath move a little more freely into the back and sides of the body, by allowing rather than forcing.
5. Notice how the body is gently rocked by breathing, including areas near the pain.
Example language (illustrative): "See if the breath can reach the back of the body. You're not pushing it there, just letting it arrive."
Watch for: deliberate deep breathing that leads to light-headedness or hyperventilation; breath-related anxiety. Then return to just noticing. It is working when the client can sense small breath-movements and some softening around the pain.

Body Scan meditation (week 1)

Purpose: establish basic awareness of the body, including areas of pain, alongside the breath. It is the first of the seven meditations, done lying or sitting. Variants run head to toe, toe to head, or from the abdomen outward, and none is better than the others [source: course overview; extra-materials pages].
Steps [synthesis]:
1. Settle and feel the body's weight and points of contact.
2. Feel the breath in the body.
3. Move attention slowly through each region in the chosen order.
4. In each region, notice the sensations that are present (pleasant, unpleasant or neutral) and let the breath seem to move through that area.
5. When the mind wanders, notice where it went and kindly return.
6. When you reach a painful area, stay at its edge first. Then approach with curiosity about its qualities (location, temperature, movement) rather than its story.
7. End by sensing the whole body breathing.
- For home practice: twice daily, with recorded audio.
Example language (illustrative): "Arriving at the lower back, just notice what's here: perhaps heat, tightness, throbbing. Can you let the breath be close to it, without needing it to change?"
Watch for:
- falling asleep (offer seated practice, eyes slightly open, or a different time of day)
- flooding when attention reaches the pain (go back to the edges or a neutral area)
- numb or absent areas (just notice them as "not much sensation here")
- It is working when the client can describe sensation in more detail and with less alarm, and notices that pain varies from moment to moment.

Breathing Anchor meditation (week 2)

Purpose: steady the attention by using the breath in the body as an anchor for wandering attention [source: course overview; free meditations page].
Variants [source: extra-materials pages]: counting the breaths, imagery, or a version with less guidance. An 8-minute free audio exists [source: free meditations page].
Steps [synthesis]:
1. Choose a posture and settle.
2. Find where the breath is clearest, for example the belly rising and falling.
3. Rest attention there and feel each in-breath and out-breath.
4. When attention is pulled away by pain, thoughts or sounds, notice that, name it lightly ("thinking", "pain"), and come back to the breath without blame.
5. Optionally count breaths, for example out-breaths up to ten, then start again.
6. Close by widening to the whole body.
Example language (illustrative): "Each time you notice you've drifted, that's a moment of mindfulness. Gently come back to the next breath."
Watch for: self-criticism about wandering; using the breath to escape pain. Remind the client that the anchor is a place to return to, not a wall against sensation. It is working when the client returns sooner and more kindly, and reports moments of rest.

Doing and being modes / "Coming to Your Senses" (week 2)

Purpose: distinguish the driven, problem-solving "doing" mode, which keeps fighting pain, from a receptive "being" mode based in sense experience. The "Coming to Your Senses" chart is adapted from Mark Williams' MBCT-related work [source: extra-materials pages].
Steps [synthesis]:
1. Teach the two modes briefly with examples from the client's day: ruminating about the pain vs feeling the sun on the skin.
2. Use the chart idea to list each sense with one daily cue for coming back to it.
3. Set a daily experiment of a few deliberate moments of shifting from thinking to sensing.
Example language (illustrative): "When you notice your mind trying to fix the pain, see if you can just listen, or feel your feet, for a few breaths."
Watch for: the client turning "being mode" into another task to succeed at. It is working when the client spontaneously reports noticing the switch.

Mindful Movement (week 3)

Purpose: gentle, adaptable movement based on yoga and Pilates. It keeps the body in condition, avoids the cycle of disuse leading to more pain and fatigue, and trains awareness of limits [source: course overview].
Material: demonstrated movements include wrist rotations, finger flicking, "warm hugging arms" and "peeling off a top". Sequences can be done lying, sitting or standing; the full pack has six 20-minute sequences [source: extra-materials pages]. Use the Breathworks recordings for exact sequences.
Steps [synthesis]:
1. Pick a starting posture.
2. Move slowly in time with the breath.
3. Use only a part of the available range, well short of the pain threshold.
4. After each movement, rest and notice the after-effects.
5. Agree in advance on the number of repetitions, so that pacing applies to the movement too.
6. Stop or downscale if pain sharpens. Imagining the movement is a valid option.
Example language (illustrative): "Do a little less than you think you can. We're interested in how it feels, not how far it goes."
Watch for:
- competitiveness, especially in groups
- delayed flare-ups the next day: ask at the next session, then reduce
- fear-avoidance stopping all movement
- Medical caveat [synthesis]: check movement suitability with the client's medical or physiotherapy team for unstable conditions.
- It is working when the client moves without bracing and reports fewer next-day flare-ups.

Three-Minute Breathing Space (from week 1–2 onward, all through)

Purpose: a short pause during any activity, resting attention on the breath. It bridges the formal meditations and daily life and helps restore a sense of control [source: course overview; free meditations page].
Origin: this practice comes from MBCT. The three-part structure below is the standard MBCT form; whether Breathworks varies it is [uncertain].
Steps:
1. Awareness: stop and notice what is here now: thoughts, feelings, body sensations.
2. Gathering: narrow attention to the breath in the body for about a minute.
3. Expanding: widen to the whole body, including any pain, then choose the next action.
Example language (illustrative): "Pause. What's here? … Now just this breath … Now the whole body, as it is. What do you need next?"
Watch for: using it only in crises. Link it to routine cues (kettle, doorways, screen breaks) and to pacing rest breaks. It is working when the client uses it without prompting at moments of stress or flare.

Mindfulness in Daily Life diary (week 3 onward)

Purpose: use diaries and symptom scoring to spot which activities aggravate symptoms, so that choices become more balanced. The book supplies a printable one-page-per-day diary [source: course overview; extra-materials pages].
Steps [synthesis]:
1. For one to two weeks, the client logs activities through the day (type and duration).
2. Alongside, they rate symptoms (pain, fatigue, mood) on a simple scale, plus rest periods and practice done.
3. Ask them to add one line on what they noticed, for example "pushed on despite warning signs".
4. Review the diary together, looking for patterns rather than judging.
Example language (illustrative): "This isn't a test. We're gathering information about how your days actually go."
Watch for:
- diary-keeping itself feeding pain preoccupation (then simplify to two or three ratings a day)
- perfectionism
- It is working when clear links between activity and later symptoms emerge.

Pacing: diary analysis, rest-period analysis and baselines (week 4)

Purpose: move from boom-and-bust to balanced activity, avoiding both overdoing on good days and collapsing on bad ones. Analysis sheets exist for the diary, for rest periods and for baselines [source: course overview; extra-materials pages].
Detail not verified: the exact procedure on those sheets is [uncertain]. The steps follow standard pain-management pacing, which MBPM states it incorporates [source: Wikipedia MBPM] [synthesis].
Steps [synthesis]:
1. Diary analysis: from the diary, identify activities that reliably lead to flare-ups, and how long the client can do each before symptoms rise.
2. Rest-period analysis: look at when, how long and how restorative rests are. Many clients rest only after collapse, or rest while still mentally tense.
3. Baselines: for each key activity (sitting, standing, walking, computer work, chores), set a starting duration the client can manage on a bad day as well as a good one. This is usually somewhat below their typical tolerance.
4. Schedule short rests before symptoms rise, and use a Breathing Space as the rest.
5. Keep to the baseline on good days too.
6. Raise baselines gradually and only after a period of stability. The rate is agreed with the client and their health team; I have not set specific increments here.
Example language (illustrative): "On a good day the temptation is to catch up on everything. What if you stopped at the time we agreed, even though you feel you could do more?"
Watch for:
- guilt or frustration at stopping early
- baselines set too high
- family pressure
- It is working when the swings between high activity and crash become smaller and total weekly activity stays steady or grows.

Blocking and Drowning analysis (week 4)

Purpose: help clients recognise their own patterns of secondary suffering. The handout charts how secondary suffering shows up as "blocking" or "drowning" and links this to the Compassionate Acceptance meditation [source: extra-materials pages].
Usual descriptions [uncertain: handout]:
- Blocking: resisting or denying the pain, pushing through, hardening, overactivity, emotional shutdown.
- Drowning: being overwhelmed by the pain, identifying with it, collapse, giving up, rumination, helplessness.
Steps [synthesis]:
1. Describe both patterns.
2. Ask the client which they recognise, physically, emotionally, mentally and in behaviour.
3. Note which pattern dominates and any switching between the two.
4. Connect each to its middle way:
  - Blocking softens through turning towards the pain.
  - Drowning steadies through anchoring and widening awareness, for example noticing the breath, the pleasant and other people.
Example language (illustrative): "When the pain spikes, do you tend to grit your teeth and push on, or does it swallow you up? Many people do both at different times."
Watch for: the client using the labels to criticise themselves. Frame them as understandable human reactions. It is working when the client can catch the pattern in the moment: "I'm blocking again."

Compassionate Acceptance meditation (week 4)

Purpose: turn towards unpleasant experience with kindness and acceptance, to reduce blocking and drowning [source: course overview; extra-materials pages; Wikipedia MBPM].
Steps [synthesis]:
1. Settle with breath and body.
2. Optionally rest a hand on the heart or on the painful area, as a gesture of care.
3. Turn attention to an area of discomfort, or to a difficult emotion.
4. Explore it gently as sensation. Let the breath soften around it, as if caring for something hurt.
5. Silently offer a kind phrase or attitude towards the experience and towards yourself.
6. If it becomes too intense, go back to the breath anchor or to a neutral area, then return.
7. Close by widening to the whole body.
Imagery: Burch is often cited using imagery of cradling pain as one would hold a hurt child. Whether this exact image is in this meditation is [uncertain].
Example language (illustrative): "See if you can let this sensation be here, held gently, the way you'd hold someone you care about who is hurting."
Watch for:
- acceptance heard as "resignation" or "giving up"; clarify that it means meeting what is already here
- grief surfacing about lost abilities; allow it and pace it
- harsh inner voice
- It is working when the client reports less tension or fear around the sensation, even if its intensity is unchanged.

Treasure of Pleasure meditation (week 5)

Purpose: deliberately seek out and savour pleasant experience that exists alongside pain. This corrects the narrowing of attention onto the unpleasant [source: course overview; Wikipedia MBPM].
Steps [synthesis]:
1. Settle and breathe.
2. Search the body for any sensation that is pleasant or neutral (warm hands, softness of the belly, contact with the chair).
3. Rest attention there and savour it for several breaths.
4. Widen to the senses: sounds, light, air temperature.
5. Notice any tendency to dismiss small pleasures.
6. In daily life, look for and briefly savour small pleasant moments, and note some of them.
Example language (illustrative): "Is there anywhere in the body that feels okay, or even nice, right now? Even the tip of a finger counts."
Watch for:
- clients who find nothing; offer neutral sensations as a start
- anhedonia or depression; screen mood
- clinging to the pleasant to avoid the pain
- It is working when the client spontaneously reports pleasant moments on bad days.

Open Heart meditation (week 6)

Purpose: equanimity. Hold pleasant and unpleasant experience together within a broader, kinder awareness, so that pain is one part of a larger field [source: course overview; Wikipedia MBPM].
Specific structure: [uncertain; not given in the sources].
Steps [synthesis]:
1. Begin with the breathing anchor.
2. Widen awareness to the whole body and the space around it, then to sounds.
3. Include any pain and any pleasant sensation together, letting both come and go.
4. Notice thoughts as passing events within this field.
5. Rest in the spacious, kindly quality of awareness itself.
Example language (illustrative): "Let awareness be wide enough to hold the ache and the warmth of your hands, both at once."
Watch for: spacing out or dissociation; return to the felt breath. It is working when the client describes the pain as "part of" experience rather than "all of it".

Connection meditation (week 7)

Purpose: move from personal to shared suffering. Recognise that others also have pain and difficulty, and extend kindness outward, reducing isolation [source: course overview; Wikipedia MBPM; Breathworks compassion blog].
Steps [synthesis, following the general pattern of loving-kindness practice, which MBPM emphasises]:
1. Begin with kindness towards oneself.
2. Bring to mind others living with pain or hardship, perhaps others in the group.
3. Then widen to people in general.
4. Silently wish them ease, using the client's own words.
5. Sense oneself as one among many.
Example language (illustrative): "Right now many people are lying awake with pain, just as you sometimes do. Can you include them in your wish for ease?"
Watch for: comparison ("others have it worse, so I shouldn't complain"); trauma triggered by images of particular people (let the client choose who to bring to mind). It is working when the client feels less alone and more connected to others.

Kindness to Self meditation (supplementary)

Purpose: this is named as part of Breathworks kindness practice [source: Breathworks compassion blog]. Its place in the 8-week sequence and its exact steps are [uncertain].
Steps [synthesis]: offer warm phrases or a gesture of care to yourself; notice resistance; return to the kindness with patience.
Watch for: strong self-criticism. Start with a friend or pet as the object and come back to yourself later.

Habit releasers (weekly)

Purpose: short daily-life experiments that interrupt automatic patterns. They are part of the book's weekly structure [source: Wikipedia MBPM]. The specific weekly habit releasers are not given here [uncertain].
Steps: follow the book's weekly habit releaser, done between sessions, and review it at the next session.

Choice: responding not reacting and the ongoing practice plan (week 8, and throughout)

Purpose: bring the skills together so the client can pause at moments of flare or stress and choose a kind, wise response. Plan for practice to continue after the course [source: course overview; Wikipedia MBPM].
Steps [synthesis]:
1. Review which meditations helped most.
2. Design a sustainable daily routine, for example one or two short practices plus Breathing Spaces at cue points.
3. Keep baselines and pacing in place.
4. Write a flare-up plan: Breathing Space, then a supportive posture, then acceptance practice, then reduced activity at baseline, then the supports to contact.
5. Point to follow-on options: Breathworks Community of Practice, follow-on sessions.
Example language (illustrative): "When the next flare comes, what's the first small thing you'll do?"
Watch for: practice falling off after the course ends; schedule a review. It is working when the client describes responding to setbacks with less panic and quicker recovery.

5. Handling problems

The sources say almost nothing about troubleshooting. Everything below is [synthesis] unless tagged otherwise. It applies MBPM principles (turning towards, primary vs secondary suffering, pacing, kindness) together with general mindfulness-teaching practice.

Pain gets worse during practice.
- Separate the sensation itself from the rise in tension or fear.
- Offer options, in this order:
  1. Move slowly to a new posture.
  2. Shorten the practice.
  3. Anchor in a neutral area such as the hands, feet or sounds.
  4. Open the eyes.
  5. Approach the edge of the pain rather than its centre.
- Ask: "What would kindness look like right now?"
- Never ask the client to sit still through escalating pain. MBPM explicitly adapts posture and keeps meditations short [source: Wikipedia MBPM].
- New or changed pain: if the pain is new, different in kind, or comes with red-flag features, the client needs medical review before you continue body-focused work.
"I just want the pain gone."
- Validate the wish.
- Use the two-arrows model: you cannot promise the first arrow will go, but you can work on the second [source: Wikipedia MBPM; Garrison interview].
- Track outcomes the client values, such as activity, sleep, mood and relationships.
Acceptance heard as resignation or defeat.
- Reframe acceptance as acknowledging what is already here so that energy goes into responding rather than fighting.
- Point to pacing as active, practical self-management.
Overwhelm, panic or dissociation, especially with trauma histories, medical trauma or pain from injury or assault.
- Use an eyes-open, external anchor (sounds, feet on the floor).
- Shorten practice and give the client control over where attention goes.
- Pause interoceptive focus on the pain area. Return to grounding and the Treasure of Pleasure approach of neutral or pleasant anchors.
- Refer for trauma-focused treatment where indicated.
Depression, hopelessness and suicide risk.
- Chronic pain raises suicide risk.
- Screen at intake and whenever there are signs of hopelessness, "drowning" or withdrawal.
- Use standard risk assessment and collaborative safety planning. Include lethal-means counselling, which in pain populations especially covers safe storage or reduced home supplies of stockpiled medication, coordinated with the prescriber.
- Do not use group meditation as a substitute for risk management.
Sleepiness and fatigue.
- Practise sitting or reclined rather than lying flat, at the client's best time of day, with eyes slightly open.
- Treat sleep that comes during practice as information about rest needs, not as failure.
Non-adherence to home practice.
- Apply pacing to meditation itself: set a baseline of minutes the client can actually manage (even 3 minutes or one Breathing Space), then build up.
- Link practice to existing routines.
- Explore blocking ("no time, I'm fine") or drowning ("what's the point") as the reasons.
- The course design of short, roughly 10-minute audio-guided practices is already meant to lower this barrier [source: course overview].
Boom-and-bust carries on despite pacing.
- Explore what the client believes about stopping (guilt, identity as a "doer", pressure from others).
- Set baselines lower.
- Involve family.
- Use a Breathing Space at the planned stop point.
Fear-avoidance: stopping all movement.
- Start Mindful Movement as imagined or micro-movements (finger flicking, wrist rotations [source: extra-materials pages]).
- Coordinate with physiotherapy.
Harsh self-criticism blocks the kindness practices.
- Start with kindness towards a friend or animal.
- Use behavioural kindness (a warm drink, a supportive cushion) before verbal phrases.
- Normalise the difficulty; the Breathworks compassion blog notes self-kindness "is not always easy".
- Consider integrating compassion-focused work.
No pleasant experience to be found (Treasure of Pleasure).
- Lower the bar to neutral sensations.
- Screen for depression or anhedonia.
Ruptures.
- Common sources: the client feels the therapist is implying pain is "in their head", or feels pushed in movement or acceptance work.
- Name it directly.
- Restate that the pain is real and that MBPM works on the reaction to it, not on whether it exists.
- Return control of pace to the client and repair openly.
Group difficulties (comparison, someone dominating, competitive movement).
- Agree norms early: no comparing, everyone moves within their own limits.
- Use the Connection theme to reframe comparison as shared experience.
Online delivery.
- Have a plan for a client who becomes distressed off camera.
- Hold emergency contact details.
- Check posture set-ups on camera.
- Most Breathworks courses now run online [source: Wikipedia Breathworks].
Discomfort with Buddhist roots.
- The course is offered as secular [source: Wikipedia Breathworks].
- Use plain language and drop references to the source tradition unless the client asks about them.
Delivering outside an accredited course.
- Use the published book and audio as client materials.
- Do not call your work the Breathworks course unless you are accredited [source: course overview; MBHI page on training routes].

Sources

Sources:

Further reading (not drawn on): Breathworks MBPM page, Breathworks approach page, the RIECS MBPM-in-cancer article, and Burch's "Opening to Pain" (Part I) on The Buddhist Centre. The Hearn & Finlay 2018 and Burch 2016 full texts are not drawn on.